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HX64088189 
QP246  .  Ad8  A  clinical  report  on 


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Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons  (for  the  Medical  Heritage  Library  project) 


http://www.archive.org/details/clinicalreportonOOadri 


:ases  Or 


By  VANDERPOEL  ADRIANS 


formal  Histology,  College  of  Ph) 


.NCE,  A.M.,  F.C.S. 


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A  CLINICAL  REPORT  ON  THE  CHEMICAL  EXAMINATION 

OF  TWO   HUNDRED   CASES   OF  HUMAN 

BREAST  MILK. 

BY    VANDERPOEL   ADRIANCE,  M.D., 
Assistant  in  Normal  Histology,  College  of  Physicians  and  Surgeons, 

AND 

JOHN    S.    ADRIANCE,   A.M.,   F.C.S., 

Analytical  Chemist  to  the  Nursery  and  Child's  Hospital,  and  the  New  York 

Infant  Asylum;    Member  of   American   Chemical   Society,  and  of 

the  Society  of  Chemical  Industry;  Fellow  of  the  American 

Association  for  the  Advancement  of  Science,  etc. 

The  observations  on  the  cases  reported  in  this  article  were 
compiled  by  Dr.  Vanderpoel  Adriance  while  resident  physician 
at  the  Nursery  and  Child's  Hospital;  simultaneously  Mr.  John 
S.  Adriance  made  the  chemical  determinations  of  the  milks  in 
the  laboratory  of  the  same  institution.  The  milks  were  pumped 
between  8  and  9  a.m.,  placed  in  a  clean  bottle,  and  taken  to  the 
laboratory  before  any  chemical  decomposition  could  set  in;  and 
in  almost  every  case  the  analysis  was  completed  before  night- 
fall. It  would  be  preferable  in  each  case  to  report  the  analysis  of 
the  entire  pumpings  of  one  breast,  but  as  this  seemed  impractic- 
able, our  analyses  represent  the  middle  milk,  the  mother  being 
instructed  to  nurse  her  infant  for  two  minutes  before  pumping 
the  sample. 

The  Nursery  and  Child's  Hospital  offers  especial  facilities  for 
the  study  of  this  subject.  Many  of  the  children  are  born  in  the 
institution,  and  those  that  are  not  have  an  accurate  history 
taken  at  the  time  of  their  admission.  Notes  and  weights  are 
recorded  daily  during  the  first  two  weeks  of  life,  and  subse- 
quently once  a  week,  so  that  a  complete  record  is  kept  for  refer- 
ence. The  fact  that  a  large  number  of  the  children  are  perfectly 
well  is  of  great  value,  as  it  admits  of  the  establishment  of  a 
normal  standard  for  the  purpose  of  comparison. 

The  cases  reported  were  under  the  daily  observation  of  the 
resident  physician.  Careful  notes  were  taken  of  the  mother's 
history,  as  well  as  the  child's.     The  cases  have  been  divided  into 


2  Adriance:     Chemical  Examination  of  Breast  Milk. 

normal  and  abnormal.  The  normal  ones  are  selected,  only  a 
clean  record  on  both  mother's  and  infant's  sides  justifying  such 
classification.  A  clean  record  implies,  on  the  part  of  the  mother, 
a  good  general  condition,  and  on  the  part  of  the  child,  no  im- 
mediate sickness  or  gastro-intestinal  symptoms,  and  a  weight 
record  which  corresponds  approximately  with  the  weight  chart 
constructed  by  Holt.  During  the  later  months  of  lactation,  how- 
ever, it  is  normal  for  a  child  to  gain  weight  less  slowly,  and  if 
nursing  is  continued  too  long,  an  actual  loss  may  occur.  In 
order  to  ascertain  the  normal  milk  of  this  period,  all  the  cases 
were  included,  unless  some  wide  variation  was  observed;  a  loss 
of  weight  pure  and  simple  at  this  period  being  insufficient  to 
define  its  abnormality.  In  this  period  are  also  included  infants 
not  entirely  breast-fed. 

To  appreciate  the  abnormal,  we  must  start  with  some  knowl- 
edge of  the  normal.  This  is  as  true  of  the  chemical  analysis  of 
human  milk  as  of  other  subjects  in  medicine,  and  in  judging  of 
the  results  of  milk  analysis,  some  physiological  standard  must  be 
set  with  which  we  shall  be  enabled  to  compare  our  results. 
Human  milk  has  in  its  composition  fat,  carbohydrate,  proteids, 
salts,  and  water.  The  first  four  represent  the  solid  constitu- 
ents, and  the  water  represents  the  vehicle  by  which  they  are 
offered  in  liquid  form.  These  constituents  exist  in  a  more  or 
less  definite  proportion  to  each  other,  and  yet  we  cannot  say 
that  all  milks  are  alike,  for  they  vary  greatly,  and  although 
we  never  have  more  than  the  above-mentioned  constituents, 
these  are  markedly  variable.  Still  some  standard  is  necessary, 
and  we  may  roughly  state  that  normal  human  breast  milk  can  be 
represented  by  figures  included  between  certain  extremes.  The 
fat  varies  from  3  to  4  percent.,  carbohydrate  from  6  to  7  percent., 
proteids  from  1  to  2  per  cent,  and  the  salts  can  be  represented  by 
.20  per  cent.  The  total  solids  amount  to  12  per  cent.,  while  the 
water,  the  complement  of  the  total  solids,  is  88  per  cent.  In 
tabular  form  the  percentages  would  appear  thus: 

Fat.  Carbohydrate.         Proteids.  Salts.  Total  Solids.  Water. 

3-4  6-7  1-2  .20.  12.  88. 

In  our  list  we  have  120  normal  cases,*  extending  from  the 
second  day  of  lactation  into  the  fifteenth  month.  The  analyses 
are  recorded  below  in  chronological  order.     We  regret  that  no 

*The  average  age  of  these  mothers  was  twenty-five  years;  fifty-five 
were  multiparas,  sixty  five  primipara;. 


Adriance:     Chemical  Examination  of  Breast  Milk. 
NORMAL  CASES. 


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Adriance  :     Chemical  Examination  of  Breast  Milk. 

Normal  Cases  (Continued). 


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Adriance  :     Chemical  Examination  of  Breast  Milk. 


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43 

6 

99      2 

28 

■14 

12 

86 

87 

'3 

26 

G. 

1 1  m.  20  d 

3 

57 

6 

79   ' 

'7 

■  15 

1 1 

69 

88 

3° 

20 

F. 

1 1  m.  21  d 

1.028 

3 

00 

6 

91 

80 

.16 

10 

92 

89 

07 

28 

G. 

1 1  m.  22  d 

3 

00 

5 

64   2 

3' 

■•'4 

1 1 

1 1 

88 

88 

19 

F. 

12  m.  13  d 

3 

23 

6 

92   1 

25 

■>3 

1 1 

55 

88 

43 

30 

F. 

12  m.  14  d 

4 

44 

7 

'9 

39 

.14 

12 

15 

87 

84 

28 

G. 

12  m.  17  d 

6 

59 

5 

81   1 

52 

■'5 

'4 

1 1 

85 

88 

24 

G. 

12  m.  18  d 

3 

49 

5 

96   1 

86 

.19 

1 1 

52 

88 

47 

20 

F. 

12  m.  28d 

1.030 

5 

34 

7 

06 

09 

.21 

12 

75 

87 

24 

34 

2 

G. 

13  m.  8  d. 

2 

53 

7 

33 

65 

■'3 

10 

65 

89 

34 

3° 

G. 

14  m.  5  d. 

4 

46 

7 

'5 

76 

.16 

12 

53 

87 

46 

20 

G. 

14  m.  15  d 

1 .030 

4 

1  I 

7 

42 

48 

■>5 

12.20 

87.79 

determination  of  the  milk  of  the  first  day  after  delivery  could  be 
made;  notwithstanding  many  attempts,  sufficient  milk  for  that 
purpose  could  not  be  obtained  at  that  time,  nor  could  a  speci- 
men be  obtained  later  than  the  fifteenth  month. 

Our  thanks  are  due  to  Dr.  Samuel  Lambert,  Dr.  J.  J.  Hull,  Dr, 
A.  M.  Thomas,  and  Dr.  L.  E.  Holt,  of  the  Medical  Board,  for 
their  kind  co-operation  and  permission  in  allowing  the  publica- 
tion of  our  results,  and  to  Drs.  Thomas  and  Holt,  who  permitted 
us  to  report  the  milks  from  their  private  cases,  which  were 
analyzed  by  us. 

The  reaction  was  uniformly  alkaline.  The  number  of  cases 
reported  hardly  warrants  a  determination  of  a  standard  to  which 
all  human  milk  should  conform.  The  averages  can  only  be  con- 
sidered as  approximations,  but  such  approximations  will  help  us 
in  studying  the  cases  in  hand,  and,  above  all,  to  appreciate  the 


Adriance  :     Chemical  Examination  of  Breast  Milk. 


subsequent  consideration  of  abnormal  cases.  The  number  of 
cases  is  unevenly  distributed  in  the  various  periods.  When  each 
group  of  cases  is  viewed  in  connection  with  the  others,  an  aver- 
age curve  for  each  constituent  can  be  determined,  representing  its 
amount  at  any  time  during  lactation. 

TABLE  SHOWING   AVERAGES  OF  NORMAL  CASES   AT   DIFFERENT 
PERIODS  OF   LACTATION. 


No.  OF 
Cases. 

Period  of 
Lactation. 

Spec. 
Grav. 

Fat. 

Carbo- 

HYDR. 

Proteids.  Sa 

LTS. 

Total 
Solids. 

Water. 

i 

2  Days. 

3  77 

5-39 

3-3' 

27 

12.98 

87.21 

2 

3d. 

1.032 

3.24 

6.22 

2.20 

25 

...98 

88.05 

2 

4d. 

1 .03 1 

2 

52 

6.40 

2.08 

26 

11.28 

88.70 

3 

5d. 

1. 031 

4 

02 

6.09 

1.96 

27 

12.35 

87.64 

5 

6  a. 

1.036 

5 

58 

6-31 

2.1 1 

24 

.2.48 

87.77 

4 

7d. 

1.029 

3 

25 

6.36 

2.09 

25 

n.96 

88.03 

2 

8d. 

2 

59 

6.44 

2.00 

21 

11.27 

88.71 

I 

9d. 

4 

76 

6.00 

1.50 

■9 

.2.46 

87-53 

2 

io  d. 

1.034 

2 

74 

6.50 

1.77 

23 

11.24 

88.74 

2 

u  d. 

1.030 

3 

51 

6.58 

2. 1 1 

24 

12.35 

87.63 

3 

12  d. 

1.030 

3 

00 

6.77 

2.03 

18 

11.99 

88.00 

i 

i  3d. 

1.030 

5 

58 

6.20 

2.13 

'9 

14.09 

85.90 

i 

14  d. 

1.030 

5 

01 

6.67 

1.30 

20 

13.19 

86.80 

8 

3  wks. 

1.031 

4 

61 

6.59 

'•55 

21 

12.98 

87.01 

9 

4  wks. 

1.029 

3 

7' 

6.71 

1.63 

21 

12.30 

87.7. 

IO 

2  m. 

1.032 

3 

22 

6.70 

'•54 

17 

11. 65 

88.33 

10 

3  m. 

1.029 

3 

65 

6.60 

1.49 

'9 

:  1.96 

88.02 

3 

4  m. 

5 

24 

6.48 

1.67 

20 

'3-59 

86.36 

8 

5  m. 

1.029 

3 

93 

6.61 

1.31 

16 

11.91 

88.07 

7 

6  m. 

1.028 

53 

7.17 

'•43 

16 

11.30 

88.70 

3 

7  m. 

1.025 

5 

81 

6.86 

1.20 

18 

14.09 

85.90 

6 

8  m. 

1.033 

3 

73 

6.72 

1.08 

'7 

11.71 

88.27 

5 

9  m. 

1.029 

4 

43 

7.00 

.86 

'4 

12.45 

87.54 

3 

10  m. 

1. 030 

2 

93 

7.07 

.86 

'5 

11.03 

88.96 

3 

1 1  m. 

1.033 

3 

88 

6.97 

.64 

18 

1 1.69 

88.20 

8 

12  m. 

1.028 

4 

'9 

6.65 

1.18 

'4 

12.21 

87.77 

5 

13  m. 

1.030 

4 

62 

6.59 

1.02 

16 

12.42 

87-57 

i 

14  m. 

2 

53 

7-33 

•65 

'3 

10.65 

89.34 

l 

15  m. 

1.030 

4 

28 

7.28 

.64 

15 

12.36 

87.62 

We  have  grouped  and  averaged  these  figures  according  to  the 
period  of  lactation.  During  the  first  two  weeks  the  changes  are 
so  rapid  and  so  marked  that  the  average  was  taken  for  every 
day,  but  only  once  a  week  during  the  third  and  fourth  weeks, 
and  subsequently  but  once  a  month. 

Fat. 
The  easiest  way  to  appreciate  the  changes  in  this  constitu- 
ent is  to  study  its  up  and  down  course  in  the  accompanying 
chart. 


Adriance  :     Chemical  Examination  of  Breast  Milk.  7 

This  demonstrates  the  fact  that  the  amount  of  fat  at  successive 
periods  is  widely  variable.  At  the  same  time  there  is  no  definite 
reason  to  account  for  this  peculiarity,  which  is  not  shown  by 
the  other  ingredients  of  human  milk — the  sugar  increasing,  and 
the  proteids  and  ash  decreasing  steadily  during  the  progress  of 
lactation.  A  study  of  the  accompanying  chart  will  show  the 
very  marked  variability  of  this  ingredient. 

This  chart  does  not  represent  the  analyses  of  one  woman's 
milk  at  successive  periods  of  lactation,  and  should  not  lead  to  the 
inference  that  any  one  woman's  milk  will  vary  to  such  a  surpris- 
ing degree.  It  does  show,  however,  that  in  a  series  of  120  cases 
the  percentage  of  fat  is  far  from  being  a  constant  figure. 

The  amount  of  fat,  then,  cannot  be  represented  by  a  regular 
curve,  as  we  shall  find  later  is  the  case  with  the  carbohydrate 
and  proteids,  yet  some  average  figure  must  be  adduced  to  repre- 
sent the  fat,  and  as  this  cannot  be  done  by  the  days,  weeks,  or 
months  of  lactation,  the  figures  must  be  obtained  at  differ- 
ent intervals,  evenly  distributed  throughout  the  entire  period. 
This  has  been  done  by  taking  the  average  of  our  list  of  120  nor- 
mal milks,  which  is  3.83  per  cent.  This  figure  should  be 
remembered  as  the  average  normal  amount  of  fat,  and  can  be 
accepted  for  any  time  from  the  colostrum  period  to  the  end  of 
lactation.  From  this  figure,  however,  wide  variations  are  to  be 
expected.  Among  our  normal  cases  are  milks  containing  as  high 
as  7.61  per  cent.,  and  as  low  as  1.31  per  cent,  of  fat.  There  is  a 
rough  relationship  between  the  amount  of  fat  and  proteid,  the 
proportion  being  3  to  1.  This  ratio  must  not  be  considered  as  a 
hard  and  fixed  one,  which  will  determine  whether  a  milk  is  to 
be  classed  as  normal  or  abnormal,  for  although  it  expresses  an 
average,  it  does  not  pertain  to  all  cases.  If  at  any  time  the  pro- 
teids are  found  in  excess  of  the  fat,  it  often  means  that  the  proteids 
are  above  their  normal  amount.  This  is  more  apt  to  occur  during 
the  colostrum  period  than  at  any  other. 

Carbohydrate. 
The  carbohydrate,  or  milk  sugar,  is  a  singularly  constant 
constituent,  and  represents  more  of  the  total  solids  than  all  the 
other  ingredients  together.  It  steadily  increases  from  the  begin- 
ning to  the  end  of  lactation,  but  this  increase  is  so  slight,  in  com- 
parison with  its  large  amount,  as  to  be  recognized  with  difficulty 
except  by  averaging  many  cases.     We  see  from  Chart  II.  that  it 


Adriance:     Chemical  Examination  of  Breast  Milk. 


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Adriance:     Chemical  Examination  of  Breast  Milk.  9 

does  not  show  marked  variations,  but  pursues  a  gradual  upward 
course.  The  lowest  per  cent,  of  carbohydrate  in  any  of  our 
normal  cases  is  5.35  per  cent.,  and  the  highest  7.95  per  cent. 

When  these  figures  are  turned  into  an  average  curve,  it  rises 
rapidly  during  the  first  two  weeks,  and  less  rapidly  thereafter, 
its  entire  increase  from  the  second  day  to  the  fifteenth  month 
reaching  from  5.80  per  cent,  to  6.96  per  cent. 

Very  little  is  known  about  the  disturbances  caused  by  milk 
sugar,  and  none  of  our  cases  has  been  classed  as  abnormal  from 
any  derangement  of  its  creation  or  from  the  chemical  determina- 
tion of  an  excess  or  scantiness  of  this  constituent.  We  do  know, 
however,  that  concerned  in  the  formation  of  fat  in  the  tissues  of 
the  infant,  it  forms  a  valuable  part  of  the  food. 

Proteids.  .  ' 

The  proteids  represent  such  an  important  element  of  the  milk, 
and  have  such  ill  effects  on  the  infant  if  excessive  or  scanty,  that 
they  should  be  studied  carefully.  It  has  been  recognized  that  the 
amount  of  the  proteids  is  greater  during  the  first  part  of  lactation 
than  at  any  other  time.  This  is  evident  in  Chart  III.,  but  can  be 
more  conveniently  studied  from  the  average  curve  seen  in  the 
same  chart,  which  shows  the  proteids  starting  on  the  second  day 
with  an  excess  represented  by  2.77  per  cent.  During  the  first 
days  there  is  a  rapid  fall,  becoming  less  evident  as  time  goes  on; 
and  after  this  the  decrease  continues,  but  less  rapidly.  *  Pfeiffer 
has  recognized  this  decrease,  and  although  his  analyses  show 
the  proteids  existing  in  larger  amounts  than  ours,  still  they  dem- 
onstrate the  same  diminution,  as  shown  by  the  following  table: 

1st  day.  7th  day.  2d  week.  2d  month.  7  months. 

8.60  per  cent.        3.40  per  cent.      2.28  per  cent.       1.84  per  cent.         1.52  per  cent. 

f  Ludwig  also  reports  a  high  per  cent,  for  cases  between  the 
twentieth  and  twenty-sixth  days.  He  places  the  proteids  for  this 
period  at  2.17  per  cent.  The  rapid  decrease  of  the  first  days 
soon  becomes  less  marked,  but  continues  nevertheless  until  the 
end  of  lactation,  when  it  is  represented  by  only  a  fraction  of  1 
per  cent. 

Salts. 

The  ash,  or  salts,  constitute  a  very  small  part  of  human  milk, 
and  its  functions  are  little  understood.  The  following  analysis 
of  the  salts  is  published  by  Harrington  and  \  Kinnicutt: 


io         Adriance:     Chemical  Examination  of  Breast  Milk. 


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Adriance:     Chemical  Examination  of  Breast  Milk.  13 

Calcium  phosphate, 23.87 

Calcium  silicate,             .         .         .     -    .         .         .  .        1.27 

Calcium  sulphate,      .......  2.25 

Calcium  carbonate,        .         .         .         .         .         .  .       3.77 

Potassium  carbonate,         ......  23.47 

Potassium  sulphate, 8.33 

Potassium  chloride,            ......  12.05 

Sodium  chloride,            .         .         .         .         .         .  .      21.77 

Iron  oxide  and  aluminum,          .....  .37 

100.00 

Like  the  proteids,  the  salts  diminish  slowly  but  steadily  from 
the  beginning.  On  the  second  day  they  average  .27  per  cent., 
but  this  figure  falls,  till  in  the  fifteenth  month  it  is  only  .14  per 
cent.     (Chart  IV.) 

Total  Solids. 

The  total  solids  are  composed  of  all  the  elements  we  have 
considered — namely,  the  fat,  carbohydrate,  proteid,  and  ash; 
and  any  variation  in  these  constituents  should  be  shown  in  the 
total  solids.  The  average  amount  of  fat,  we  have  shown,  is  3.83 
per  cent.,  and  this  has  been  accepted  as  our  standard  through- 
out, so  that  it  will  cause  no  variation.  The  ash,  represented  by 
only  a  fraction  of  1  per  cent.,  is  so  small  as  to  be  practically 
thrown  out  of  consideration.  We  must  look  to  the  carbohydrate 
and  proteid,  then,  for  any  change  in  the  amount  of  the  total  sol- 
ids. These,  however,  very  nearly  compensate  each  other,  as 
the  sugar  increases  and  the  proteid  decreases  steadily  during  lac- 
tation, thus  acting  as  balances  to  each  other.  So  the  total  solids 
remain  very  constant,  when  lactation  is  considered  as  a  whole, 
but  nevertheless  show  variation  from  month  to  month,  as  the 
chart  demonstrates.  The  average  for  the  total  solids  is  12.20  per 
cent,  until  the  seventh  month.  After  this  it  suffers  a  gradual  de- 
cline until,  at  the  fifteenth  month,  it  is  1 1.50  per  cent.    (Chart  V.) 

Water. 
The  water  is  the  complement  of  the  total  solids,  and  as  the 
latter  decrease,  the  former  increases,  so   that   during  the  last 
months  there  is  a  slight  gain. 

Specific  Gravity. 
The  average  specific  gravity  is  1.030.     The  proteids  and  fat 
are  the  chief  determining  agents  of  the  specific  gravity.    Any  in- 
crease in  the  fat  lowers  the  specific  gravity,  and  any  decrease 


14         Adriance:     Chemical  Examination  of  Breast  Milk 


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Adriance:     Chemical  Examination  of  Breast  Milk.  \<? 

raises  it.  The  proteids  exert  exactly  the  opposite  effect — the 
greater  their  quantity,  the  higher  the  specific  gravity,  and  vice 
versa.  We  should,  therefore,  expect  the  specific  gravity  to  be 
lowest  when  the  fats  are  highest  and  the  proteids  lowest;  and 
highest  when  the  conditions  are  reversed.  From  this  it  may  be 
inferred  that  the  specific  gravity  should  fall  as  the  proteids  and 
total  solids  diminish  in  the  later  months  of  lactation.  And  this 
we  find  to  be  the  case,  but  the  change  is  so  slight,  and  our  list  of 
specific  gravities  so  small,  that  it  will  not  be  worth  recording 
till  further  observations  are  made. 


COMPUTED  AVERAGES   FOR   HUMAN   MILK   DURING   LACTATION, 
TABULATED   FROM   THE   AVERAGE   CURVES. 


Period. 

Spec. 
Grav. 

Fat. 

Carbo-  n 

Pro 

rEiDS.  A 

SH. 

Total 

Water. 

hydr. 

Solids. 

2  Days. 

1.030 

3.81 

5.80     2 

77 

27 

12.20 

87. So 

3d. 

1.030 

3 

83 

5.90     2 

20 

26 

12. 20 

87.80 

4d. 

1.030 

3 

83 

6.00     2 

10 

25 

12.20 

87.80 

5d. 

1.030 

3 

83 

6. 10     2 

00 

12.20 

87.80 

6d. 

1.030 

3 

83 

6.16     1 

95 

24 

12  20 

87.80 

yd. 

1.030 

3 

83 

6.22     1 

90 

24 

[2.20 

87.80 

8d. 

1.030 

3 

83 

6.29 

87 

23 

12.20 

87.80 

9d. 

1 .030 

3 

83 

6.37     1 

84 

22 

12.20 

S7.80 

10  d. 

1.030 

3 

83 

6.42 

80 

22 

12.20 

87.80 

11  d. 

1 .030 

3 

83 

6.48     1 

78 

21 

12.20 

87.80 

12  d. 

1.030 

3 

83 

6.53     1 

75 

21 

12.20 

87.80 

i3d. 

1.030 

3 

83 

6.59     1 

72 

20 

12.20 

87.80 

14  d. 

1.030 

3 

83 

6.63     1 

70 

20 

12.20 

87.80 

3  wks. 

1.030 

3 

83 

6.67     1 

62 

19 

12.20 

87.80 

4  wks. 

1.030 

3 

83 

6.68     1 

58 

'9 

12.20 

87.80 

2  m. 

1.030 

3 

83 

6.70     1 

55 

18 

12.20 

87.80 

3  m. 

1.030 

3 

83 

6.72     1 

48 

18 

12.20 

87.80 

4  m. 

1.030 

3 

83 

6.74     i 

40 

'7 

12.20 

87.80 

5  m. 

1.030 

3 

83 

6.76     1 

32 

'7 

12.20 

87.80 

6  m. 

1.030 

3 

83 

6.78     1 

25 

16 

12.20 

87.80 

7  m. 

1.030 

3 

83 

6.80     1 

18 

16 

12.20 

87.80 

8  m. 

1.030 

3 

83 

6.82     1 

1 1 

16 

12.12 

87.88 

9  m. 

1.030 

3 

83 

6.84 

04 

16 

12.04 

87.96 

10  m. 

1.030 

3 

83 

6.86 

97 

15 

11.95 

88.05 

1 1  m. 

1.030 

3 

83 

6.88 

90 

15 

11.86 

88.14 

12  m. 

1 .030 

3 

83 

6.90 

83 

'5 

11.77 

88. 2  3 

13  m. 

1.030 

3 

83 

6.92 

77 

"4 

11.68 

88.32 

14  m. 

1.030 

3 

83 

6.94 

70 

>4 

11.59 

88.41 

15  m. 

1.030 

3 

83 

6.96 

63 

'4 

1 1.50 

88.50 

So  far  we  have  considered  the  general  changes  taking  place 
in  mother's  milk  during  lactation  as  a  whole,  but  there  are  two 
periods  which  deserve  our  especial  attention;  these  are  com- 
monly known  as  the  colostrum  period  and  the  later  months  of 
lactation. 


1 6         Adriance  :     Chemical  Examination  of  Breast  Milk. 

Colostrum  Period. 
The  characteristics  of  the  milk  of  this  period  are: 
(i)  The  presence  of  colostrum  corpuscles.      Normally  these 
corpuscles  persist  in  the  milk  from  seven  to  ten  days. 

(2)  Laxative  property  upon  the  infant. 

(3)  Yellow  color  of  the  milk,  which  is  marked  at  first,  fades 
gradually,  and  disappears  about  the  same  time  as  the  colostrum 
corpuscles. 

(4)  Chemical  characteristics. 

It  seems  to  us  that  the  chemical  analysis  of  the  colostrum 
milk  is  of  greater  importance,  as  a  characteristic  of  the  milk  of 
this  period,  than  any  of  the  others  just  mentioned,  and  that  it  is 
insufficient  to  say  that  the  colostrum  corpuscles  are  the  sine  qua- 
non,  upon  whose  disappearance  the  milk  ceases  to  belong  to  the 
colostrum  period.  Arbitrary  as  it  is,  we  have  considered  the 
colostrum  period  as  covering  the  first  two  weeks. 

During  the  first  days,  when  the  breasts  are  assuming  their 
functional  activity,  we  should  expect  irregularities  in  the  secretion 
which  would  not  occur  later  when  the  function  is  established.  It 
is  not  infrequent  to  find  the  fat  very  high  during  this  period,  or, 
on  the  other  hand,  very  low.  The  sugar  is  lower  on  the  second 
day  than  at  any  other  time,  but  rises  steeply,  and  at  the  end  of 
two  weeks  its  curve  has  traveled  well  upward.  The  proteids,  as 
already  remarked,  pursue  just  the  opposite  course,  being  higher 
on  the  second  day  than  at  any  other  time,  but  fall  rapidly  during 
the  first  few  days,  and  less  rapidly  subsequently.  From  2.77 
per  cent,  on  the  second  day,  it  goes  to  1.7  per  cent,  on  the  four- 
teenth day.  This  excess  of  proteids  during  the  colostrum  period 
is  of  great  importance,  as  we  shall  see  in  the  consideration  of  ab- 
normal milks. 

The  ash,  like  the  proteids,  is  higher  at  this  time  than  at  any 
other. 

Examples  to  show  the  changes  during  the  first  part  of  lacta- 
tion.    Mother  20  years  of  age,  primipara. 

3  days.       6  days. 
Fat,            .        .         .        4-52 
Carboh.,        .         .         .     5.86 
Proteids,     .         .         .         2.37  2.13 

Salts, 26  .25 

Total  Solids, 
Water, 


6  days. 

26  days 

4.29 

5.26 

6.52 

7.05 

1.93 

1.66 

.20 

.22 

12.95 

14.19 

87.04 

85.80 

Adriance:     Chemical  Examination  of  Breast  Milk.         17 

Mother  19  years  of  age.     Grav.  ii. 

2  days.  10  days. 

Fat 3.77  2.64 

Carboh., 5.39  6.62 

Proteids,           ....           3.31  1.70 

Salts, 27  .23 

Total  Solids,             .         .        .         12.78  11.19 

Water,          .         .         .         .             87.21  88.80 


Mother  23  years  of  age.     Grav.  ii. 

6  days.  1  mo.  17  days. 

Fat,          .....          4.30  4.08 

Carboh., 5.38  6.91 

Proteids,           ....           2.79  1.44 

Salts, 23  .19 

Total  Solids,    ....         12.71  12.61 

Water,        .        .        .        .        .    87.28  87.38 


The  Later  Months  of  Lactation. 

During  the  later  months,  when  the  function  of  lactation  is 
preparing  for  cessation,  certain  changes  are  to  be  expected.    The 
quantity  of  fat  still  shows  marked  variation.     The  sugar,  gradu- 
ally increasing  from  the  beginning,  continues  to  increase.     The 
proteids,  the  exact  opposite  of  the  sugar,  have  been  gradually 
decreasing,  and  continue  to  decrease.      The  total  solids,  which 
remained  constantly  at  12.20  percent,  till  the  seventh  month, 
begin  to  show  a  slight  decrease  at  the  eighth  month,  falling  to 
1 1.50  per  cent,  at  the  fifteenth  month.      The  quantity  of  ash  is 
now  very  small,  as  it  has  been  steadily  diminishing  from  the 
start. 

Examples  of  milks   during  the   later  months   of  lactation. 
Mother,  34  years;  grav.  ii. ;  good  supply. 

13  mo.  8  days. 
Fat,     .  .  .  .  .     2.53 

Carboh.,    .....  7.33 

Proteids,  .  .  .  .  .       .65 

Salts,         .  .  .  .  .  .13 


Total  Solids,    ....  10.65 

Water,       .  .  ,  ,  ,89.34 


Adriance:     Chemical  Examination  of 

Breast  Milk. 

Mother,  30  years 

Fat,     . 
Carboh.,    . 
Proteids, 
Salts, 

;  primipara;  fair  supply. 

\2  mo.  14  days. 

•  4-44 
7.19 

•  -39 
.14 

Total  Solids, 
Water, 

12.  is 
87.84 

Influences  Causing  Variations  Outside   of  the   Period  of 
Lactation. 

Outside  of  the  period  of  lactation  there  are  influences  which 
affect  the  milk.  Clinical  experience  has  taught  that  in  selecting 
a  wet-nurse,  a  primipara  is  preferable  to  a  multipara,  and  the 
age  to  be  preferred  is  between  twenty  and  thirty.  Ludwig  states 
that  the  milk  of  multipara;  contains  less  fat  than  that  of  primi- 
para;, and  that  women  between  twenty  and  thirty  years  of  age 
have  less  proteids,  sugar  and  salts,  but  more  fat  in  their  milk, 
than  women  between  thirty  and  forty  years.  In  considering 
these  questions,  it  will  not  do  to  average  a  number  of  these 
cases,  and  to  classify  them  without  regard  to  the  other  influences. 
The  comparison  of  the  milk  of  primipara;  and  multipara;  must 
be  made  only  at  corresponding  periods  of  lactation.  This  has 
been  done  in  the  following  lists  of  twenty-three  primipara;  and 
twenty-three  multipara;.  The  extremes  of  lactation,  that  is,  be- 
fore the  fifteenth  day  and  after  the  ninth  month,  were  excluded. 
The  average  period  of  lactation  of  both  classes  is  three  months. 
The  average  age  of  mothers  is  twenty-five  years. 


Fat, 

Carboh., 
Proteids, 
Salts, 

Total  Solids,      .  .       12.41  12. 11  12.20 

Water,         .  .  87.57  87-87  87-8° 

By  comparing  these  figures,  we  see  that  the  milk  of  the 
primipara;  of  this  period  of  lactation  is  richer  in  fats,  proteids, 
salts,  and  total  solids,  than  average  milk;  the  sugar,  however,  is 


Average  of  23 
primiparae, 
third  month. 

Average  of  23 
multipara;, 
third  month. 

Computed 

average  for  third 

month. 

4.06 

3.67 

3.83 

6.52 

6.85 

6.72 

I.6l 

'•35 

I.48 

.18 

•17 

••7 

Adriance:     Chemical  Examination  of  Breast  Milk.  19 

less  abundant.  The  milk  of  multipara;  is  just  the  reverse.  Such 
being  the  case,  we  are  selecting  primiparae  as  wet-nurses  with 
justice,  for  we  are  obtaining  a  richer  milk. 

To  ascertain  the  correctness  of  preferring  the  milk  of  a  wet- 
nurse  between  twenty  and  thirty  years  of  age,  a  number  of  ob- 
servations have  been  made  upon  equal  numbers  of  primiparae 
and  multipara;,  and  at  the  same  average  period  of  lactation.  No 
considerable  difference  has  been  detected.  If  any  exists,  it  will 
be  demonstrated  only  after  consideration  of  a  larger  number  of 
cases. 

Although  we  cannot  prove  that  a  wet-nurse  between  twenty 
and  thirty  years  of  age  offers  a  better  milk,  still  a  young  woman 
is  more  likely  to  be  healthy  than  one  who  is  older,  and,  taking 
all  things  into  account,  will  be  more  desirable  in  the  house- 
hold. 

The  great  law  of  variation  is  so  active  in  determining  the 
character  of  human  milk,  that  its  scientific  study  is  rendered 
difficult.  No  sooner  had  a  classification  of  cases  been  attempted, 
than  differences  arose  which  seemed  at  first  insignificant.  These 
demonstrated  the  individual  idiosyncrasy  of  the  children.  One 
would  thrive  on  one  kind  of  milk,  and  another  on  another. 
What  would  be  detrimental  to  one  child,  would  prove  healthy 
food  for  another.  Sometimes  the  chemical  analysis  showed 
results  which  differed  widely  from  the  average,  and  yet  the  in- 
fant maintained  good  health.  It  is  exceptional  for  the  infant  to 
maintain  good  health  under  these  conditions,  and  yet  the  milk  is 
debarred  from  being  classed  as  abnormal. 

The  following  analyses  are  given  as  examples  of  what  differ- 
ent children  thrive  on: 

Mother,  29  years;  grav.  ii. ;  good  supply.  Infant,  female; 
birth  weight,  8  lbs.  2  oz.  (3670  grammes);  6  days  old,  weight, 
7  lbs.  1 1  oz.  (3480  grammes). 

Fat,           .....  4.81 

Carboh.,         .....             .  .      6.75 

Proteids,              .            .            .            .  1.84 

Ash,               .            .            .            .  .        .26 


Total  Solids,         ....  13-70 

Water,  .  .  .  .  .86.28 


20         Adriance:     Chemical  Examination  of  Breast  Milk. 

Mother,  19  years;  grav.  i. ;  supply  abundant.  Infant,  female; 

birth  weight,  8  lbs.  7  oz.  (3840  grammes) ;  7  days  of  age,  weight, 

8  lbs.  2  oz.  (3684  grammes). 

Fat,  .  .  .  .  .  2.93 

Carboh.,         .  .  .  .  .6.55 

Proteids,  .  .  .  .  2.70 

Ash,  .  .  .  .  .        .20 


Total  Solids,        ....  12.38 

Water,  .....    87.61 

Mother,  20  years;  grav.  i. ;   supply  good.  Infant,  female; 

birth  weight,   5  lbs.    is  oz.   (2690  grammes);  16  days  of  age, 
weight,  6  lbs.  10  oz.  (3000  grammes);  spec.  grav.  1.030. 

Fat,          .....  4.29 

Carboh.,        .            .             .            .  .6.52 

Proteids,              .            .            .            .  1.93 

Salts,              .            .            .            .  .        .20 


Total  Solids,         ....  '2.95 

Water,  .....     87.04 

Mother,   27  years  of  age;   grav.    ii. ;    supply  good.    Infant, 
male;  birth  weight,  6  lbs.  9  oz.  (2970  grammes) ;  29  days  of  age, 
weight,  10  lbs.  8  oz.  (4761  grammes);  spec.  grav.  1.033. 
Fat,  .....  1.85 

Carboh.,        .  .  .  .  .6.90 

Proteids,  .  .  .  .  1.34 

Salts,  .  .  ,  .  .        .25 

Total  Solids,        .  .  .  10.36 

Water,  .....    89.63 

Mother,  21  years;  grav.  i. ;  good  supply.  Infant,  male;  birth 
weight,  6  lbs.  9  oz.  (3070  grammes) ;  4  months,  2}  days,  weight, 
17  lbs.  13  oz.  (8070  grammes);  very  fat. 

Fat,  .....  5.83 

Carboh.,         .  .  .  .  .6.18 

Proteids,  .  .  .  1.89 

Salts,  .  .  .        .17 


Total  Solids,        ....  14.09 

Water,  .  .  .  .  .    85.90 


Adriance  :     Chemical  Examination  of  Breast  Milk.  2 1 

Mother,  24  years;  primipara;  good  supply.  Infant,  male; 
birth  weight  normal;  5  months,  1  day.  old,  weight,  13  lbs.  8  oz. 
(6122  grammes). 

Fat,           .....  2.01 

Carboh.,         .            .            .            .  .6.99 

Proteids,               .            .            .            .  2.60 

Salts,              .            .            .            .  .13 


Total  Solids,        ....  11.73 

Water,  ._  .  .  .    88.26 

In  these  cases  there  are  great  variations  in  the  constituents, 
yet  in  none  was  any  disturbance  of  nutrition  observed.  Another 
reason  why  no  strictly  scientific  classification  of  the  cases  could 
be  made  was  the  fact  that  the  same  woman's  milk  varied  at  dif- 
ferent times;  and  it  was  not  to  be  expected  that  the  analysis  of 
one  milk  would  hold  good  for  the  following,  or  even  that  the 
morning's  analysis  would  correspond  with  that  of  the  evening. 

Mother,  21  years;  primipara.     Infant,  2  months,  23  days. 

Fat,      . 
Carboh.,    . 
Proteids, 
Salts, 

Total  Solids,    . 
Water, 

Even  different  parts  of  the  same  nursings  differ.  If  we  divide 
the  pumpings  from  the  same  breast  into  three  equal  parts,  keep- 
ing first,  second  and  third  portions  separate,  we  shall  find  differ- 
ences as  follows : 

Fore  Milk.  istCase.  2d  Case.  3d  Case.  Average. 

Fat, 

Carboh., 
Proteids, 
Salts, 

Total  Solids, 
Water, 


IO  A.  M. 

4  P.  M. 

4.4O 

2.00 

6.93 

6.64 

2.06 

•47 

■23 

•'5 

I3.66 

9.28 

86.33 

90.70 

3.66 

1.98 

1. 19 

2.27 

6.82 

6.56 

7.00 

6.79 

1.45 

.58 

.56 

.86 

.16 

.12 

••5 

.14 

12. 1 1 

9.26 

8.95 

10. 1 1 

87.88 

90.73 

91.04 

89.88 

22  Adriance:     Chemical  Examination  of  Breast  Milk. 

Middle  Milk.              ist  Case.  2d  Case.  3d  Case.  Average. 

Fat,          .             .  .         4.40  2.00  1.99            2.79 

Carboh.,        .             .               6.93  6.64  7.04            6.87 

Proteids,             .  .        2.06  .47  .69            1.07 

Salts,             .             .                 .23  .15  .16              .18 


Total  Solids, 

.       1 3.66 

9.29 

9.87 

10.94 

Water, 

86.33 

90.70 

90.12 

89.05 

Strippings. 

Fat, 

5.11 

3.12 

2.78 

3.65 

Carboh., 

6.92 

7. 1 1 

6.93 

6.99 

Proteids, 

1. 00 

.72 

•95 

.89 

Salts, 

.20 

•17 

.  12 

.16 

Total  Solids,       .  .       13.25        11. 14        10.79  n-73 

Water,  .  .  86.74       88.85        89. 20  88.26 

From  these  figures  it  will  be  seen  that  the  fat  and  total  solids 
represent  a  larger  per  cent,  in  the  middle  milk  than  in  the  fore 
milk,  and  in  the  strippings  than  in  the  middle  milk.  The  aver- 
ages also  show  a  rise  in  the  carbohydrate,  but  regarding  any 
changes  in  the  other  constituents,  our  number  of  cases  is  not 
sufficient  to  warrant  drawing  any  conclusions.  §  Harrington  has 
determined  the  same  increase  in  the  fats  and  total  solids  in  cows' 
milk. 

The  samples  from  the  two  breasts  also  show  a  variation,  the 
milk  taken  at  the  same  time  from  the  right  and  left  showing  ap- 
parent differences,  as  the  following  cases  will  illustrate: 


Right  breast.  Left  breast. 

Spec.  gray.  1.032.     Spec.  gray.  1.032 


Fat, 

Carboh., 
Proteids, 
Salts, 

Total  Solids, 
Water, 


3-73 

3.48 

6.77 

6.54 

..38 

2.47 

.22 

.26 

12. 15 

'3-74 

87-53 

86.25 

Adriance:     ChemicalExamhiaiion  of  Breast  (Milk. 


23 


Right  breast.  Left  breast. 

Spec.  grav.  1.030.     Spec.  grav.  1.030. 

2.52 

6.62 


3-32 

6.76 

1.62 

.21 


11.93 


Right  breast. 

^eft  breast. 

Spec.  grav.  1 .029. 

Sp 

'.c.  grav.  1.027 

3-77 

5.6l 

.      6.89 

6.77 

2.69 

I. 19 

.20 

.20 

13.56 

'3-79 

.    86.43 

86.20 

Fat, 

Carboh., 
Proteids, 
Salts, 

Total  Solids, 
Water, 


Fat, 

Carboh., 
Proteids, 
Salts, 

Total  Solids, 
Water, 


Each  one  of  these  cases  shows  variations  which  are  apparent, 
and  in  some  cases  quite  marked.  We  know  that  the  quantity 
and  quality  of  the  milk  depend  largely  upon  the  demand  for  it, 
and  especially  upon  the  character  of  the  nursing.  If  the  infant  is 
hearty,  and  nurses  vigorously,  the  quantity  is  increased  and  the 
quality  improved. 

The  next  case  is  the  milk  of  a  woman  who  nursed  her  own 
healthy  baby  from  the  right  breast,  and  a  poor,  miserable  foster- 
child  from  the  left  breast.  The  foster-child  labored  under  the 
disadvantage  of  its  weakness,  and  being  nursed  irregularly  and 
grudgingly. 

Right  breast.  Left  breast. 

Spec.  grav.  1.028.     Spec.  grav.  1.029. 

Fat,          ....  3.96  2.45 

Carboh.,         ....  7.04  7.04 

Proteids,              .            .            .  1.17  1.02 

Salts,               ....  .20  .20 


Total  Solids, 
Water, 


12.38 
87.61 


10.73 
80.26 


The  next  analysis  is  that  of  a  woman  who  had  but  one  func- 
tionating breast,  the  other  having  been  dried  up  at  three  weeks 
on  account  of  a  cracked  nipple. 


Adriance  :     Chemical  Examination  of  Breast  tMilk. 

Right  breast. 

Fat,          .            .            .            .            .  3. 1 1 

Carboh.,  .            .            .            .  .      7.33 

Proteids,               ....  .98 

Ash,  .            .            .            .  .15 


Total  Solids,        .  .  .  .  1 1.60 

Water,  .....    88.39 

The  baby  is  eight  months,  ten  days  old,  perfectly  healthy,  and 
above  the  normal  weight.  The  case  demonstrates  that  one 
healthy  breast  can  provide  enough  good  milk  for  an  infant's 
nourishment. 

Among  our  cases  are  those  of  mothers  who  are  nursing  only 
their  own  children,  those  who  are  nursing  their  own  and  half 
nursing  a  foster-child  beside,  and  those  nursing  two  children. 
After  careful  analysis  and  compilation  of  these  cases,  no  evidence 
was  found  to  show  that  increased  frequency  of  the  nursings 
modified,  in  any  way,  the  character  of  the  milk. 

A  review  of  the  foregoing  observations  leads  to  the  following 
conclusions: 

(1)  The  fat  shows  no  constant  changes  during  lactation.  Its 
most  marked  characteristic  is  its  variability. 

(2)  The  carbohydrate,  on  the  second  day  of  lactation,  is  low, 
but  rises  rapidly  during  the  first  few  days.  This  increase  con- 
tinues, but  less  rapidly,  up  to  the  end  of  lactation. 

(3)  The  proteids  pursue  a  course  the  reverse  of  the  carbo- 
hydrate. 

(4)  The  salts  diminish  similarly  to  the  proteids. 

(5)  The  total  solids  are  represented  by  12.20  percent,  till  the 
later  months  of  lactation,  when  they  decrease  steadily. 

(6)  The  colostrum  period  has  low  carbohydrate,  with  a 
tendency  to  increase  rapidly,  and  high  proteids  and  salts,  with  a 
tendency  to  decrease  rapidly. 

(7)  The  milk  of  the  later  months  of  lactation  shows  a  de- 
ficiency in  proteids,  ash,  and  total  solids. 

(A  study  of  Abnormal  Milks  will  be  reported  in  the  next 
number.) 

*  Beitrage  zur  Physiologie  der  Muttermilch  und  ihren  Beziehungen  zur 
Kinderunahrung. — Jarb.  f.  Kinderh.,  Leip.,  1883,  n.  F.  xx.,  359-402. 

f  Ueber  Veranderungen  der  Frauenmilch  und  des  Colostrums  bei 
Krankheiten  der  Wochnerinnen. — Arch.  f.  Gynaek.,  Berl.,  1894,  xlvi..  342- 
357- 

X  Rotch's  Pediatrics.  §  Rotch's  Pediatrics. 


Adriance:     Chemical  Examination  of  Breast  Milk.         25 

Abnormal  Milks. 

Under  this  head  have  been  classified  only  those  milks  which 
have  shown  themselves  abnormal  by  their  effect  upon  the  child, 
or  have  been  found  by  chemical  analysis  to  differ  materially  from 
average  milk.  Chemical  analysis  alone,  however,  offers  no  cri- 
terion, for  in  many  cases,  as  has  been  previously  stated,  the 
infant  adapts  itself  to  its  conditions,  and  thrives  on  a  milk  which 
one  should  suppose  ill  adapted  for  food. 

To  secure  a  healthy  milk,  the  mother  should  have: 

(1)  A  good  constitution. 

(2)  Healthy  environment. 

(3)  Simple,  nutritious  diet  with  enough  albumenous  food. 

(4)  Regular  exercise  in  the  open  air. 

These,  with  the  exception  of  the  first  mentioned,  are  simple 
hygienic  conditions  which  every  mortal  should  enjoy,  but  on  a 
nursing  woman  they  have  a  definite  influence,  not  only  on  her 
health,  but  on  her  milk,  and  in  this  way  a  disregard  of  them  is  as 
harmful  to  the  infant  as  to  the  mother.  A  woman  with  a  wast- 
ing disease  cannot  yield  a  nutritious  milk,  and  a  woman  whose 
general  condition  is  below  par  is  liable  to  dry  up  prematurely. 
A  robust  woman  offers  the  best  milk. 

Under  the  head  of  environment  comes  a  happy  home  life  with 
a  minimum  of  worry.  Nervousness  of  any  kind  causes  a  rise  of 
the  proteids,  and  if  the  woman  is  constitutionally  nervous,  this 
may  cause  such  a  constant  rise  as  to  make  the  milk  unfit  for  a 
food.  A  woman  in  our  wards  could  not  live  happily  with  her 
neighbors,  and  frequently  indulged  in  heated  argument  with 
marked  show  of  temper.  After  these  quarrels  her  child  was 
always  upset  for  a  day  or  two.  A  simple,  nutritious  diet,  with 
a  proper  allowance  of  meat,  is  necessary,  as  it  keeps  up  the  gen- 
eral tone  of  the  milk.  The  milk  of  an  underfed  woman  shows  a 
reduction  in  total  solids.  A  lack  of  meat  reduces  the  fats  and 
total  solids,  and  on  the  other  hand,  an  excessive  meat  diet  raises 
the  fats  too  high. 

A  judicious  amount  of  exercise  in  the  open  air  is  necessary, 
for  it  is  a  general  tonic  to  the  milk.  When  the  milk  is  scanty,  a 
little  exercise  often  restores  the  proper  amount;  and  the  baby 
who  has  been  crying  from  hunger,  and  lagging  behind  in  weight, 
improves  in  a  wonderful  manner.  A  lack  of  exercise  allows  the 
proteids  to  increase.  On  the  other  hand,  excessive  exercise  wor- 
ries and  tires  out  the  mother,  and  acting  like  other  untoward 


26         Adriance  :     Chemical  Examination  oj  Breast  Milk. 

nervous  influences,  results  in  the  production  of  too  large  an 
amount  of  proteids,  causing  the  same  result  as  if  exercise  had 
been  neglected. 

Each  one  of  these  conditions,  if  nicely  regulated,  is  a  source 
of  good;  on  the  other  hand,  their  abuse  or  neglect  is  sure  to 
result  only  in  injury.  Moreover,  the  regulation  of  these  condi- 
tions varies  according  to  the  idiosyncrasy  of  different  women, 
and  in  each  case  it  must  be  determined  just  how  much  of  each 
is  required.  In  some  cases  it  is  only  by  repeated  examinations 
of  the  milk  and  rearrangement  of  the  manner  of  life  that  a  satis- 
factory condition  is  reached. 

Excessive  Fats. 

In  judging  from  the  chemical  analysis  alone,  without  regard 
to  the  effect  of  the  milk  upon  the  child,  we  should  often  wrongly 
judge  the  fats  to  be  in  excess,  as  we  have  already  stated  that  this 
constituent  is  subject  to  great  variation,  and  that  an  unduly  large 
amount  may  occur  at  any  period  of  lactation;  there  is  no  partic- 
ular time  when  this  condition  is  to  be  expected.  A  large  amount 
of  fat  may  tax  the  digestive  system  too  severely,  and  is  often 
followed  by  spitting  up  after  nursing,  vomiting,  or  by  intestinal 
symptoms.  Such  disturbances,  if  allowed  to  persist,  are  natur- 
ally followed  by  lack  of  nutrition  and  a  loss  of  weight,  which 
must  receive  treatment.  This  consists  mainly  in  cutting  down 
the  amount  of  albumen  in  the  mother's  diet,  until  the  per  cent, 
of  fat  in  the  milk  agrees  with  the  child ;  but  should  this  be  carried 
too  far,  it  results  in  a  general  impoverishment  of  the  milk  in  all 
its  solids,  with  a  reduction  of  the  total  solids,  so  that  although 
we  have  corrected  the  excess  of  fats,  the  nourishing  properties 
of  the  milk  are  impaired,  and  the  nursing  infant  loses  weight 
from  partial  starvation. 

A  deficiency  of  fat  never  causes  any  intestinal  symptoms  that 
we  have  been  able  to  determine.  It  is  generally  considered  that 
a  deficiency  of  fat  causes  constipation,  but  this  we  have  not 
proved.  Constipation  has  more  often  seemed  to  be  due  to  an 
insufficiency  of  milk,  or  an  insufficiency  of  total  solids,  so  that 
not  enough  is  left  to  pass  through  the  alimentary  canal  as  waste 
material. 

A  fine  child,  doing  nicely,  continued  to  gain,  and  kept  above 
normal  weight  till  three  months  of  age.  The  character  of  the 
milk  is   shown   by  the  accompanying   analysis.      Mother,  27 


Adriance  :     Chemical  Examination  of  Breast  Milk.         27 

years;  grav.  ij. ;  healthy;  good  supply.  Infant,  male;  birth 
weight  6  lbs.  9  oz.  (2970  grammes) ;  when  29  days  old,  weight 
10  lbs.  8  oz.  (4761  grammes). 

Spec.  grav.  1.033. 
Fat,  .....  1.85 

Carbohydrates,  ....       6.90 

Proteids,  .  .  .  .  1.34 

Salts,  .....        .25 


Total  Solids,        .  .  .  .  10.36 

Water,  .  .  .  .  .89.63 

At  three  months  the  infant  began  to  vomit,  have  green  move- 
ments, and  to  cry  with  colic.  Still  he  continued  to  gain  weight, 
though  more  slowly  than  normal,  until  the  fifth  month,  when  it 
was  found  that  his  weight  was  beginning  to  fall  off.  He  con- 
tinued to  vomit  and  cry,  while  the  bowels  were  in  worse  condi- 
tion. He  seemed  really  sick. 
Analysis  at  five  months: 

Spec.  grav.  1.022. 
Fat,  .  .  .  .  .  8.44 

Carbohydrates,  .  .  .  .6.15 

Proteids,  .  .  .  .  .91 

Salts,  .  .  .  .  .        .17 


Total  Solids,        ....  15-69 

Water,  .  .  .  .84.90 

The  analysis  of  the  milk  explained  the  source  of  trouble. 
There  was  a  decided  change  from  the  milk  we  had  analyzed  on 
the  twenty-ninth  day.  Then  the  fats  were  but  1.85  percent., 
but  now  they  had  run  up  to  8.44  per  cent.  This  quantity  of  fat 
is  so  very  unusual  and  excessive  that  there  was  no  hesitation  in 
blaming  it  for  the  child's  condition,  and  steps  were  immediately 
taken  to  correct  it. 

First  of  all,  as  a  general  regulator,  the  mother  was  told  to 
take  a  walk  in  the  fresh  air  every  day,  and  to  stop  eating  meat 
and  eggs  altogether.  Two  days  later  the  milk  showed  a  marked 
improvement  in  the  baby,  and  four  days  later  the  fat  had  fallen 
to  3.40  per  cent.,  the  specific  gravity  to  1.029.  There  was  no 
more   vomiting,   and   the   movements   were  yellow   and   well 


28         Adriance:     Chemical  Examination  of  Breast  Milk. 

digested.  This  proved  that  our  treatment  had  been  well 
directed.  The  child,  however,  continued  to  lose  weight  and  to 
cry,  although  he  had  no  gastro-intestinal  symptoms  or  physical 
signs  of  disease.  Three  weeks  after  the  last  analysis  another  ex- 
amination was  made,  which  showed  the  following  result. 

Analysis  at  five  months,  twenty-two  days: 

Spec.  grav.  1.051. 

Fat,  .....  1.66 

Carbohydrates,         .  .  .  .  7.25 

Proteids,  .  .  ..  .  .61 

Salts,  .  .  .  .  .         .19 


Total  Solids,        ....  9.72 

Water,  .  .  .  .  .90.27 

We  now  found  that,  through  a  misunderstanding,  the  mother 
had  continued  to  desist  from  albumenous  diet  completely.  Asa 
result,  although  the  child  had  no  intestinal  symptoms,  he  did 
not  receive  enough  nourishment,  and  consequently  did  not  be- 
gin to  gain  weight  normally  until  this  mistake  had  been  recti- 
fied. This  case  demonstrates  how  an  excess  of  fat  may  be  cor- 
rected, and  how  the  treatment  must  be  used  properly,  and  not 
carried  too  far. 

Rotch,  of  Boston,  has  said  that  the  amount  of  fat  in  the  milk 
can  be  controlled  by  the  amount  of  nitrogenous  material  in  the 
mother's  diet.  The  treatment  in  the  following  cases  was  not  in- 
dicated, but  was  prescribed  to  prove  or  disprove  his  statement. 

Mother,  19  years;  grav.  ij. ;  healthy;  good  supply.  Infant, 
female;  birth  weight,  7  lbs.  9  oz.  (3430  grammes);  6  days  old^ 
weight,  6  lbs.  (2734  grammes). 

Analysis  at  six  days: 

Spec.  grav.  1.033. 
Fat,  .....  2.)^ 

Carbohydrates,  .  .  .  .6.49 

Proteids,  .  .  .  .  1.23 

Salts,  .  .  .  .  .        .24 


Total  Solids,        ....  10.31 

Water,  ,  ,  ,  .  .89.68 


Adriance  :     Chemical  Examination  of  Breast  Milk.  29 

The  infant  cried  a  great  deal,  vomited,  and  had  green  and 
undigested  movements.  The  milk  did  not  suggest  anything 
out  of  the  ordinary,  but  to  determine  if  we  could  increase  the 
amount  of  fat  at  will,  the  mother  was  put  upon  an  albumenous 
diet  of  eggs  for  breakfast,  meat  for  dinner  and  supper,  and  meat 
broth  between  times.  The  vegetables  were  limited.  The  child's 
condition  remained  about  the  same,  and  in  two  days  the  fats 
had  increased  to  4.20  per  cent.,  and  the  specific  gravity  had 
fallen  to  1.029.  For  six  days  this  diet  was  kept  up.  The  infant 
still  cried  a  great  deal  at  night,  and  the  movements  continued 
green,  although  the  weight  increased.  The  milk  was  analyzed 
on  the  twelfth  day,  and  showed  the  fat  still  high. 

Analysis  at  twelve  days: 

Spec.  grav.  1.027. 

Fat, 4.57 

Carbohydrates,  ....       6.00 

Proteids,  .  .  .  .  1.77 

Salts,  .  .  .  .  .        .23 


Total  Solids,         ....  12.59 

Water,  .  .  .  .  .     87.40 

The  diet  was  then  discontinued,  and  one  lacking  in  albumen- 
oids  was  substituted.  After  twelve  days,  a  third  analysis  was 
made. 

Analysis  at  twenty-four  days: 

Spec.  grav.  1.029. 
Fat,  .  .  .  .  .  3.77 

Carbohydrates,  .  .  .  .6.89 

Proteids,  .  .  .  .  2.69 

Salts,  .  .•  .  .  .         .20 


Total  Solids,        .  .  .  .  13.56 

Water,  .....     86.43 

The  child  was  now  in  good  condition — healthy,  above 
weight,  and  sleeping  well — while  the  fat  had  fallen  as  we  had 
desired.  The  fat  had  increased  and  diminished  as  we  had  antici- 
pated with  the  administration  and  withdrawal  of  the  meaty  diet 
respectively. 


}o         Adriance:     Chemical  Examination  of  Breast  Milk. 

Another  case  demonstrates  the  same  point. 

Mother,  20  years  of  age;  grav.  ij. ;  healthy;  abundant  supply- 
Infant,  male;  birth  weight,  6  lbs.  12  oz.  (3070  grammes);  21 
days  old,  weight,  8  lbs.  10  oz.  (391 1  grammes). 

Analysis  at  twenty-one  days: 

Spec.  grav.  1.030. 
Fat,  .....  6.61 

Carbohydrates,  .  .  .  .6.20 

Proteids,  .  .  .  .  .94 

Salts,  .  .  .  .  .        .19 


Total  Solids,        ....  '3-9^ 

Water,  .....     86.03 

Two  days  after  this  analysis  was  made  the  mother  was  put 

on  albumenous  diet  to  see  if  the  fat  could  be  kept  in  excess. 

When  twenty-seven  days  of  age,  or  four  days  after  the  change 

of  diet,  another  analysis  was  made. 

Analysis  at  twenty-seven  days: 

Spec.  grav.  1.023. 
Fat,  .  .  .  .  .  5.21 

Carbohydrates,  ....       5.35 

Proteids,  .  .  .  .  1.81 

Salts,  .....        .28 


Total  Solids,        ....  12.66 

Water,  .  .  .  .  .87.32 

This  shows  the  fat  in  excess,  although  it  had  fallen  some,  but 
changing  to   non-albumenous   diet,   a   marked   difference   was 
noted;  in  six  days  the  fats  had  fallen  to  2.56  per  cent. 
Analysis  at  one  month,  four  days: 

Spec.  grav.  1.031. 
Fat,  .....  2.56 

Carbohydrates,  .  .  .  .6.83 

Proteids,  .  .  .  .  1.57 

Salts,  .  .  .  .  .17 


Total  Solids,        .  .  .  .  n.  14 

Water,  .  .  .  ...     88.85 


Adriance:     Chemical  Examination  of  Breast  Milk.         31 

Excessive  Proteids. 
The  proteids  are  apt  to  be  excessive  under  certain  conditions, 
These  conditions  are  a  lack  of  exercise,  too  rich  a  diet,  and  nerv- 
ousness. Excessive  proteids  occur  frequently  during  the  first 
days  of  lactation.  When  excessive,  they  show  themselves  by 
interfering  with  the  infant's  digestion,  the  symptoms  of  which 
are  vomiting  and  frequent  movements  of  the  bowels,  which  may 
contain  curds  of  undigested  proteid.  The  movements  are  some- 
times green  and  sometimes  yellow,  the  green  movements  being 
more  frequent  during  the  first  days  of  nursing.  The  baby  suffers 
from  colic,  and  on  account  of  the  disturbance  of  the  digestive 
organs,  there  may  be  a  disturbance  of  nutrition  sufficient  to 
cause  a  loss  of  weight.  We  shall  consider  the  treatment  of  this 
condition  during  the  first  days  of  lactation  later,  but  for  the  pres- 
ent will  speak  of  the  treatment  in  general. 

The  treatment  of  this  condition  is  both  prophylactic  and  cura- 
tive. Its  most  constant  cause  is  lack  of  exercise.  A  woman  of 
sedentary  habits,  especially  if  her  diet  is  too  rich,  should  be  ad- 
vised to  take  a  suitable  amount  of  exercise,  regulation  of  this 
function  being  the  most  reliable  factor  in  reducing  the  proteids. 
By  drinking  a  larger  amount  of  water,  the  mother  can  dilute  her 
milk  so  that  the  total  solids,  and  consequently  the  proteids,  will 
be  represented  by  a  smaller  per  cent.,  or  the  milk  may  be 
pumped  and  diluted  with  water  directly,  when  it  can  be  fed  from 
the  bottle. 

Mother,  29  years;  grav.  ij. ;  healthy;  good  supply.  Infant, 
female;  birth  weight,  5  lbs.  8  oz.  (2500  grammes);  at  3  months 
of  age,  weight,  12  lbs.  4  oz.  (5556  grammes). 

Analysis  at  three  months: 

Spec.  grav.  1.034. 

Fat, 1.38 

Carbohydrates,  .  .  .  .7.19 

Proteids,  .  .  .  .  2.72 

Salts,  .  .  .  .  .        .16 


Total  Solids,        .            .            .            .'  u-43 

Water, 88.55 

For  ten  days  the  infant  had  frequent  yellow  and  undigested 
stools.  There  had  been  no  vomiting,  but  the  child  cried  a  great 
deal  with  colic.     The  foster-child  was  in  the  same  conditon. 


jj2         Adriance  :     Chemical  Examination  of  Breast  Milk. 

This  case  shows,  both  in  the  case  of  the  mother's  child  and  the 
foster-child,  the  usual  results  of  a  milk  with  high  proteids. 

The  next  case  demonstrates  some  principles  in  the  treatment 
of  excessive  proteids,  which  Rotch  has  shown  consists  in  regula- 
tion of  the  exercise. 

Mother,  23  years;  grav.  i. ;  nervous  constitution;  poor  gen- 
eral condition;  good  supply  of  milk.  Infant  1  month  prema- 
ture, and  under  weight  at  birth,  but  at  1  month,  7  days  of  age 
it  weighed  6  lbs.  (2721  grammes). 

Analysis  at  one  month,  seven  days: 

Spec.  grav.  1.035. 
Fat,  .  .  .  .  .  4. 13 

Carbohydrates,  .  .  .  .6.79 

Proteids,  ....  2.06 

Salts,  .....        .26 


Total  Solids,         ....  13.23 

Water,  .  .  .  .  .86.76 

The  infant  had  been  having  five  or  six  green  movements 
with  curds  every  day  since  birth.  The  mother  had  taken  no  ex- 
ercise, was  losing  sleep,  and  was  very  nervous.  This  case 
showed  high  proteids,  as  we  shall  find  later  is  the  case  in  pre- 
maturity. The  mother  was  in  such  poor  condition,  it  was 
feared  that  exercise  would  be  an  injury  rather  than  a  help.  Still 
fresh  air  was  necessary,  and  driving  each  day  was  recommended. 
She  was  advised  to  eat  meat  but  once  a  day,  instead  of  three 
times,  and  to  drink  large  quantities  of  water. 

Six  days  after  the  inauguration  of  the  treatment,  the  child, 
though  much  improved,  still  suffered  from  indigestion.  Move- 
ments were  frequent,  but  the  curds  had  diminished  to  small 
flakes.  Child  had  gained  six  ounces  in  the  four  days.  This  im- 
provement in  the  stools  was  due  to  the  diminution  of  the  pro- 
teids, as  seen  in  the  following  analysis. 

Analysis  at  one  month,  thirteen  days: 

Spec.  grav.  1.031. 
Fat,  .....  4-38 

Carbohydrates,         .  .  .  .       7. 10 

Proteids,  .  .  .  .  1.66 

Salts,  .....         .24 


Total  Solids,       ....  13.37 

Water,         ...  .86.62 


Adriance  :     Chemical  Examination  of  Breast  Milk.         33 

During  the  following  week  the  movements  became  less  fre- 
quent, and  there  was  a  gain  of  one  ounce  daily.  One  month  after 
the  beginning  of  treatment  the  movements  still  contained  a  few 
fine  curds,  but  were  reduced  in  frequency  to  the  normal  number, 
while  the  child's  weight  had  increased  two  pounds,  twelve 
ounces. 

Excessive  Proteids  During  the  Colostrum  Period. 

In  normal  cases  we  have  found  the  proteids  highest  during  the 
colostrum  period.  This  excess  influences  the  color  of  the  stools. 
After  the  four  days  during  which  the  infant  is  passing  meconium, 
the  stools  become  brown  or  brownish  green.  After  this  the 
color  of  the  stools  may  change  to  the  yellow  of  a  normal  infant's 
stool,  or  it  may  continue  green,  or  green  alternating  with  yel- 
low, for  several  days.  In  an  older  child  such  a  green  color  of 
the  stools  often  indicates  an  excess  of  proteids  in  the  milk,  which 
requires  treatment.  In  the  stools  of  infants  of  this  age  a  green 
color  so  often  exists  that  it  demands  no  treatment,  unless  accom- 
panied by  other  symptoms  of  disease.  It  is  to  be  considered 
simply  the  natural  consequence  of  the  high  proteids  in  the  milk 
of  this  period.  If  it  becomes  more  marked,  curds  appear  in 
addition  to  the  green  color  of  the  stools.  The  movements  be- 
come increased  in  frequency,  and  there  may  be  vomiting,  with 
rise  of  temperature.  Such  a  hard  strain  upon  the  new-born 
infant  during  the  first  days  of  life  may  change  into  a  toxic  gastro- 
enteritis, with  feeble,  rapid  pulse  and  cyanosis,  which  is  difficult 
to  differentiate  from  a  septic  condition  of  the  system. 

Mother,  24  years  of  age;  grav.  i. ;  healthy;  good  supply  of 
milk.  Infant,  male;  birth  weight,  7  lbs.  12  oz.  (3520  grammes) ; 
4  days  of  age,  weight,  6  lbs.  13  oz.  (3100  grammes). 

Fat,  .  . 

Carbohydrates, 

Proteids,  .... 

Salts,  .... 

Total  Solids,        .... 
Water,  .... 

The  high  proteids  in  this  case  upset  the  infant,  and  showed 
in  frequent  green  and  undigested  movements,  uric  acid  stain 


3.12 

4-93 

3-.  49 

.24 

11.82 

88.17 

34         Adriance:     Chemical  Examination  of  Breast  Milk. 

upon  the  napkins,  and  an  afternoon  temperature  of  1030.  At 
the  end  of  one  week  the  disturbing  proteids  had  fallen  to  1.85 
per  cent,  and  after  another  week  of  no  treatment  the  green  in 
the  stools  disappeared,  and  the  child  began  to  improve. 

Mother,  31  years;  primipara;  fair  general  condition;  fair  sup- 
ply of  milk.  Infant,  male;  weight  at  birth,  8  lbs.  12  oz.  (3960 
grammes);  five  days  old,  weight,  7  lbs.  12  oz.  (3420  grammes). 

Fat,  .....  2.83 

Carbohydrates,         .  .  .  .4.80 

Proteids,  .  .  .  .  3.24 

Salts,  .....        .39 


Total  Solids,        .  .  .  .  11.30 

Water,  .  .  .  .  .88.69 

Fed  on  the  milk  represented  in  this  analysis,  the  infant  lost 
steadily,  and  had  very  bad  movements.  This  general  condition 
failed,  and  on  the  twelfth  day  the  circulation  was  poor,  the  face 
dusky,  and  the  child  was  in  as  miserable  a  condition  as  if  the 
system  were  poisoned.  On  the  twelfth  day  he  was  taken  from 
the  mother  and  put  upon  a  woman's  breast,  whose  child  was 
older  and  doing  nicely.  The  stools  and  general  condition  imme- 
diately improved,  and  in  ten  days  the  child  had  improved  so 
much  that  it  was  hoped  he  could  digest  his  own  mother's  milk, 
even  if  the  proteids  had  not  become  normal.  This  was  tried. 
The  milk  was  not  analyzed  at  this  time,  but  it  apparently  agreed 
with  the  child,  and  one  month,  seventeen  days  after  delivery  the 
child  was  still  doing  well,  and  the  analysis  showed  a  marked 
reduction  in  the  amount  of  proteids. 

Analysis  at  one  month,  seventeen  days: 

Fat,          .....  4-22 

Carbohydrates,         .            .            .  .5.64 

Proteids,              .            .            .            •  1.81 

Salts,             .            .            •            •  -15 


Total  Solids,       .             .            .            .  n.83 

Water, 88.16 


Adriance:     Chemical  Examination  of  Breast  Milk.  35 

Any  extra  worry  or  nervousness  may  increase  the  amount  of 
proteids  during  the  first  days  of  lactation.  The  following  case 
illustrates  this  point.     The  infant  had  colic  and  bad  movements. 

Mother,  24  years;  primipara;  healthy;  abundant  supply; 
excessively  nervous,  and  at  times  hysterical.  Infant,  male; 
weight  at  birth,  6  lbs.  8  oz.  (2940  grammes) ;  7  days  old,  weight, 
6  lbs.  5  oz.  (2860  grammes). 

Spec.  grav.  1.030. 

Fat 3.74 

Carbohydrates,         .  .  .  .6.09 

Proteids,  .  .  .  .  2. 1 5 

Salts,  .  .  .  .  .        .34 


Total  Solids,        ....  12.35 

Water,  .  .  .  .  .87.64 

Prematurity. 

In  every  case  of  prematurity  in  which  we  have  had  an  oppor- 
tunity to  analyze  the  milk,  we  have  found  distinguishing  charac- 
teristics. The  variations  of  the  colostrum  period  are  present, 
but  exaggerated  in  the  proteids.  This  increase  in  the  proteids  ex- 
tends over  a  longer  interval  than  in  ordinary  colostrum  milk,  and 
is  not  easily  dispelled.  It  consequently  taxes  the  delicate  diges- 
tive organs  of  the  untimely-born  infant  for  a  longer  time  than  is 
usual.  The  sugar,  the  complement  of  the  proteids,  is  low  at  this 
time.     The  cases  reported  were  all  one  month  premature. 

Cases  One  Month  Premature. 


2  days. 

3  days. 

7  days. 

Spec.  grav.  1.032. 

Spi 

;c.  grav. 

Spec.  grav.  1.031 

Fat,       . 

.        I.83 

2.48 

2.68 

Carbohydrates, 

5-55 

5.38 

5.38 

Proteids, 

.      3.18 

2.91 

3.08 

Salts, 

.27 

.23 

.26 

Total  Solids,     . 

.     10.83 

I  I.04 

1 1.42 

Water, 

89. 16 

88.95 

88.57 

36         Adriance:     Chemical  Examination  of  Breast  Milk. 

Analysis  of  the  same  case  at  successive  times : 

4days.                    17  days.  1  mo.,  10  days. 

Spec.  grav. Spec.  grav. Spec.  grav.  1.030. 

Fat,       .             .             .      3.39                   3.32  3.3} 

Carbohydrates,      .            5.02                  4.43  6.64 

Proteids,           .            .      4.90                  3.88  1.71 

Salts,           .            .              .31                    .26  .10 


13.66 

86.32 

1 1. 91 

88.08 

11.79 
88.20 

5  days. 
Spec.  grav.  1.030. 

.       2.S8 

16  days. 
Spec.  grav.  1.027. 

3.29 

5.99 

6.O9 

•       2.37 

I.90 

.27 

.22 

.      I  1 .20 

88.79 

11.47 
88.52 

Total  Solids, 
Water, 


Fat, 

Carbohydrates, 
Proteids, 
Salts, 

Total  Solids,    . 
Water, 

The  last  two  cases,  analyzed  on  successive  days,  not  only 
demonstrate  an  excess  of  proteids  during  the  first  days,  but  also 
that  in  prematurity  this  excess  shows  a  tendency  to  persist 
longer  than  usual.  We  have  known  the  proteids  to  remain  over 
2  per  cent,  into  the  second  month  of  lactation.  Premature  chil- 
dren are  naturally  delicate,  and  ill  adapted  to  stand  this  extra 
strain  so  early  in  life. 

Treatment  at  the  Colostrum  Period. 

The  treatment  of  excessive  proteids  during  the  colostrum 
period  is  difficult.  Naturally  during  child-bed  the  mother's  diet 
must  be  limited,  and  exercise  upon  which  we  ordinarily  rely  for 
reducing  the  proteids  is  impossible.  The  milk  can  be  pumped, 
diluted  with  water,  and  fed  from  the  bottle;  or  it  can  be  diluted 
by  the  administration  of  large  quantities  of  water  to  the  mother. 
In  some  of  the  less  severe  cases,  less  frequent  nursing  will  prove 
of  benefit,  taking  water  from  the  bottle  in  the  intervals.  This 
condition  is  usually  temporary,  and  will  adjust  itself  in  a  few 
days. 

In  cases  of  prematurity,  as  it  is  hard  to  say  how  long  this 
difficulty  will  persist,  it  is  often  wise  to  give  the  infant  to  a 


Adriance  :     Chemical  Examination  of  Breast  Milk.         37 

wet-nurse  whose  milk  has  been  demonstrated  to  be  good  by  its 
effect  upon  her  child  and  by  analysis.  In  the  meantime  the 
mother's  breast  should  be  stimulated  by  pumping,  so  that  the 
secretion  will  not  dry  up,  but  in  time  serve  as  a  proper  food. 

We  have  had  very  good  fortune  in  the  management  of  pre- 
mature babies  in  our  institution.  Much  of  our  success  was  due 
to  careful  nursing,  but  recognizing  the  excessive  proteids,  the 
treatment  was  regulated  accordingly,  and  no  doubt  deserves  a 
large  part  of  the  credit. 

Abnormalities  Toward  the  End  of  Lactation. 

The  most  marked  changes  in  the  milk  in  the  later  months  of 
lactation  are  a  reduction  of  the  proteids  and  total  solids.  These 
seem  of  little  importance,  but  are  not  to  be  lightly  considered. 
The  diminution  in  the  proteids  is  the  natural  forerunner  of  the 
cessation  of  lactation,  and  means  that  the  milk  is  deteriorating; 
on  the  other  hand,  if  the  proteids  are  high,  lactation  will  prob- 
ably continue  for  some  time. 

The  fats,  certainly,  are  no  criterion  of  the  condition  of  the 
milk;  neither  is  the  sugar,  but  a  proper  amount  of  proteids  in  the 
milk  indicates  its  tone  is  good.  The  physiologists  tell  us  that 
fats  and  carbohydrate  can  be  made  in  the  human  body,  but  that 
proteids  cannot  be,  so  that  they  have  to  be  taken  in  as  such.  A 
scanty  amount  of  proteids  then  means  that  the  nursing  infant  will 
have  to  get  along  as  best  it  can  under  unfavorable  conditions. 
We  have  observed  many  such  cases,  and  been  led  to  think  that 
at  this  time  the  proteids  are  the  backbone  of  the  milk,  and  really 
represent  its  nourishing  properties  better  than  any  other  guide 
which  we  at  present  possess.  This  condition,  forced  upon  the 
child,  causes  a  general  weakness  of  the  constitution,  which 
results  in  anaemia,  fretfulness,  a  falling  below  the  normal  gain  in 
weight,  delayed  dentition,  and  proneness  to  gastro-enteritis. 
The  latter  symptom  may  not  appear  till  some  time  after  we  have 
begun  the  tardy  process  of  weaning.  As  a  rule  the  first  sign  of 
approaching  danger  is  a  tendency  to  gain  weight  more  slowly 
than  normal.  A  healthy  infant  should  gain  from  four  to  eight 
ounces  weekly  for  the  first  six  months,  and  from  two  to  four 
ounces  weekly  during  the  second  six  months.  If  the  child's 
weight  falls  below  this  standard  for  any  length  of  time,  or  is  sta- 
tionary, or  there  is  a  positive  loss,  we  should  try  to  find  the 
cause  at  once.      It  may  be  that  the  infant  is  getting  insufficient 


38        Adriance:     Chemical  Examination  of  Breast  €Milk. 

milk.  This  can  be  determined  by  weighing  before  and  after 
each  nursing.  The  milk  should  be  analyzed,  and  if  the  total 
solids  and  proteids  are  found  low,  their  absence  must  be 
supplied. 

Treatment  of  Normal  Cases  in  the  Later  Months  of  Lactation. 

The  hygiene  of  the  mother's  life  must  be  carefully  regulated. 
On  account  of  certain  deficiencies  which  we  have  seen  occur 
normally  in  human  milk  of  this  period,  certain  additions  must  be 
made  to  the  diet.  By  the  seventh  or  eighth  month  the  infant's 
pancreas  is  functionating  so  well  that  we  can  rely  upon  it  to  con- 
vert starch,  and  some  carbohydrate,  such  as  barley  gruel,  should 
be  given  in  addition  to  the  milk.  On  account  of  the  lack  of  pro- 
teids, we  must  give  a  substitute  of  some  form  of  animal  food.  In 
this  way  a  deficiency  in  the  mother's  milk  can  be  partially 
supplied. 

Weaning  should  begin  at  the  ninth  month,  and  in  the  early 
stages  of  this  process  we  should  use  a  modified  milk  containing 
low  proteids,  taking  care  not  to  force  upon  the  infant's  digestion 
an  amount  of  cow's  proteids  equal  to  or  greater  than  that  which 
the  mother  has  been  offering,  for  it  is  known  that  the  proteids  of 
cow's  milk  form  a  tough  curd,  which  are  indigestible  in  compari- 
son with  human  proteids.  The  number  of  bottle  feedings  and  the 
amount  of  proteids  should  be  gradually  increased.  Under  this 
treatment,  even  if  the  child  continues  to  lose  weight  for  a  time, 
we  can  feel  that  the  stomach  is  gradually  becoming  accustomed, 
and  eventually  will  be  able  to  digest  a  stronger  diet.  At  any 
rate  we  shall  have  the  satisfaction  of  keeping  the  child  from 
gastro-enteritis,  to  which  its  constitution  would  be  particularly 
susceptible  at  this  time. 

Management  of  Abnormal    Cases  in    the  Later  Months  of 
Lactation. 

If  the  mother  is  anaemic,  a  tonic  containing  iron  is  indicated. 
Holt  has  shown  that  malt  increases  the  total  solids  in  human 
milk,  and  we  have  found  its  use  very  beneficial  at  this  time. 
The  form  we  have  used  has  been  Maltine.  The  mother's  diet 
should  be  increased  with  the  addition  of  cow's  milk.  A  good 
form  in  which  to  prescribe  the  latter  is  a  milk  punch.  Exercise 
in  the  fresh  air  is  important.     Antiseptic  massage  of  the  breast 


Adriance  :     Chemical  Examination  of  Breast  (Milk.         39 

for  its  local  stimulating  effect  was  used  on  A.  M.  Thomas'  serv- 
ice at  the  hospital.  In  the  later  months  of  lactation  we  cannot 
hope  to  bring  the  original  tone  back  to  the  milk,  but  we  can 
hope  to  keep  it  from  degenerating  further  till  the  child  has  been 
weaned. 

Mother,  20  years;  primipara;  healthy;  fair  supply.  Infant, 
male;  birth  weight,  normal;  11  months,  25  days  of  age,  weight, 
17  lbs.  4  oz.  (7824  grammes). 

Fat,           .  .             .             .             .             2.24 

Carbohydrates,  .            .            .            .6.86 

Proteids,  .            .            .            .              .36 

Salts,             .  .            .            .            .        .13 


Total  Solids,        .  .  .  .  9.59 

Water,  .  .  .  .  .90.40 

The  infant  was  very  anaemic,  and  had  been  losing  weight  for 
two  months.  This  case  shows  the  usual  result  of  protracted 
nursing,  but  all  milk  does  not  show  such  degeneration,  for  some 
mothers  retain  their  milk  in  its  strength  till  much  later  in  lacta- 
tion, and  in  such  cases  nursing  can  be  continued  longer. 

Milk  Degenerating  Earlier  in  Lactation. 

Changes  in  the  mother's  milk  due  to  preparation  for  the  ces- 
sation of  lactation  may  begin  at  any  time  when  the  mother's 
health  is  so  poor  as  to  affect  the  milk.  Many  mothers  are  never 
able  to  nurse  their  children  for  any  length  of  time,  as  the  milk 
dries  up  prematurely.  Under  such  conditions  we  find  the  same 
chemical  changes  that  would  normally  occur  later  in  lactation; 
or  this  condition  of  the  milk  may  persist  for  many  months,  and 
the  infant  suffer  from  lack  of  food,  while  the  mother,  perhaps 
misled  by  her  abundant  supply,  is  at  a  loss  to  account  for  the  fail- 
ing health  of  her  baby.  Under  such  circumstances,  a  better 
prognosis  can  be  given  than  later  in  lactation,  for  the  mother  may 
be  so  influenced  by  treatment  that  the  milk  is  brought  up  to  its 
standard. 

Mother,  19  years;  primipara;  poor  general  condition;  scant 
supply.  Infant,  male;  birth  weight,  normal;  7  months,  6  days 
of  age,  weight,  10  lbs.  (4535  grammes).  Poor,  delicate,  anaemic 
child,  subject  to  bronchitis.  Has  been  under  weight  since  one 
month  of  age. 


5.6 1 

6.89 

.63 

•17 

40  Adriance  :     Chemical  Examination  of  Breast  Milk. 

Fat,  ..... 

Carbohydrates, 

Proteids,  .... 

Salts,  .... 

Total  Solids,        .  .  .  .  1 3. 32 

Water,  .  .  .  .  .     86.67 

This  milk  showed  low  proteids,  which  often  exist  in  a  poor 
milk,  even  when  the  total  solids  are  not  below  the  normal. 

Mother,  24  years;  primipara;  fair  supply.  Infant,  male; 
birth  weight,  above  normal;  weight  kept  above  normal  till  2 
months  of  age,  and  since  then  has  gained  less  slowly;  4  months, 
27  days  of  age,  weight,  13  lbs.  8  oz.  (6122  grammes). 

Spec.  grav.  1.050. 

Fat, 3.95 

Carbohydrates,         .  .  .  .7.45 

Proteids,  .  .  .  .  .34 

Salts,  .  .  .  .  ..15 


Total  Solids,        .  .  .  .  11. 91 

Water,  .....     88.08 

Mother,  35  years;  grav.  iv. ;  nursed  second  child  for  five 
months,  when  the  milk  dried  up;  nursed  third  child  three 
months,  when  milk  dried  up.  At  this  lactation  had  an  abund- 
ant supply,  but  was  run  down.  She  nursed  her  own  infant,  and 
a  foster-child  beside.  Own  infant,  female;  birth  weight,  8  lbs. 
8  02.  (3854  grammes) ;  2  months,  13  days  old,  weight,  8  lbs.  12  oz. 
(3968  grammes) ;  much  under  weight.  The  weight  had  been 
falling  off  rapidly  for  three  weeks,  but  the  child  did  not  seem 
sick,  had  no  vomiting  or  bowel  trouble,  and  on  physical  exami- 
nation nothing  was  discovered  but  craniotabes.  There  were  no 
other  sign  of  rickets. 

Analysis  at  Analysis  at  Analysis  at 

2  mos.,  13  days.       2  mos.,  20  days.      2  mos.,  28  days. 
Spec.  grav.  1.030.     Spec.  grav.  1.030.     Spec.  grav.  1 .026. 

Fat,    .             .  .       3.00  3.78  3.69 

Carbohydrates,  .            6.97  7.06  6.81 

Proteids,        .  .75  .15  1.36 

Salts,        .  .             .18  .16  .18 

Total  Solids,  10.90  11. 15  12.06 

Water,  .  .    89.09  88.83  87.93 


Adriance:     Chemical  Examination  of  Breast  Milk.         41 

The  chemical  examination  of  the  milk  disclosed  the  diagnosis 
of  this  case.  The  proteids  and  total  solids  were  low.  Nothing 
was  done  for  a  week,  and  the  child  continued  to  fail. 

At  the  end  of  a  week  another  analysis  was  made,  and  the 
proteids  had  fallen  very  low,  although  the  total  solids  had  risen 
25  per  cent.  The  mother  was  told  to  walk  in  the  fresh  air  every 
day,  and  given  a  tonic  containing  iron,  arsenic  and  strychnine, 
a  tablespoonful  of  Maltine  three  times  a  day,  and  extra  milk  and 
milk  punches.  At  the  end  of  eight  days  a  decided  change  for 
the  better,  both  in  the  mother's  condition  and  in  the  child,  took 
place.  The  child  had  gained  fourteen  ounces,  and  was  doin'g 
nicely.  The  analysis  showed  a  good  milk,  instead  of  the  poor 
milk  of  eight  days  previous. 

Mother,  22  years;   primipara;   thin,  and  very  nervous;  fair 

supply;  complains  of  lack  of  appetite.      Infant,  birth  weight,  8 

lbs.  8  oz.  (3854  grammes);   2  months,  16  days  of  age,  weight, 

14  lbs.  (6350  grammes). 

2  mos.,  16  days.       2  mos.,  25  days. 
Spec.  grav.  1.033.     Spec.  grav.  1.035. 

Fat,     .              .  .              .              .         .67  1.36 

Carbohydrates,  .            .            .            7.14  7.25 

Proteids,         .  .             .             .        .93  .21 

Salts,         .  .             .             .               .22  .17 


Total  Solids,  .  .  .      8.95  9.01 

Water,      .  ...  .  91.04  90.98 

The  infant  was  doing  well,  but  the  analysis  was  made  be- 
cause the  mother  was  so  much  worried  and  pulled  down.  From 
the  observation  of  many  previous  cases  which  had  presented  a 
similar  chemical  condition,  it  was  believed  that  the  milk  was 
likely  to  dry  up  at  no  distant  date. 

Nine  days  later  the  milk  was  analyzed  again,  and  showed 
further  reduction  in  the  proteids.  By  this  time  the  mother 
thought  her  milk  was  flowing  less  freely,  and  extra  modified 
milk  was  given  the  infant.  The  mother  continued  to  worry, 
and  five  days  later  the  breasts  secreted  so  little  milk  that  the 
baby  was  put  entirely  upon  the  bottle.  This  proved  to  have 
been  wise,  for  in  three  days  the  breasts  were  entirely  free  from 
milk.  Two  weeks  later  the  mother  was  in  bed  with  nervous 
prostration. 

Low  proteids  and  total  solids  may  persist  for  some  time,  but 
when  their  reduction  is  rapid,  it  is  a  warning  that  lactation  may 


42         Adriance  :     Chemical  Examination  of  Breast  Milk. 

cease  unless  proper  treatment  is  inaugurated.  An  insufficient 
diet  may  lower  the  tone  of  the  milk,  reducing  the  proteids  and 
total  solids,  but  unlike  the  milk  preparing  for  the  cessation  of 
lactation,  its  tone  is  promptly  restored  when  the  diet  is  in- 
creased. 

Summary. 
(ij    Excessive  fats  or  proteids   may  cause   gastro-intestinal 
symptoms  in  the  nursing  infant. 

(2)  Excessive  fats  may  be  reduced  by  diminishing  the  nitro- 
genous elements  in  the  mother's  diet. 

'    (3)  Excessive  proteids  may  be  reduced  by  the  proper  amount 
of  exercise. 

(4)  Excessive  proteids  are  especially  apt  to  cause  gastro- 
intestinal symptoms  during  the  colostrum  period. 

(5)  The  proteids,  being  higher  during  the  colostrum  period 
of  premature  confinement,  present  dangers  to  the  untimely-born 
infant. 

(6)  Deterioration  in  human  milk  is  marked  by  a  reduction  in 
the  proteids  and  total  solids,  or  in  the  proteids  alone. 

(7)  This  deterioration  takes  place  normally  during  the  later 
months  of  lactation,  and  unless  proper  additions  are  made  to  the 
infant's  diet,  is  accompanied  by  a  loss  of  weight,  or  a  gain 
below  the  normal  standard. 

(8)  When  this  deterioration  occurs  earlier,  it  may  be  the 
forerunner  of  the  cessation  of  lactation,  or  well-directed  treat- 
ment may  improve  the  condition  of  the  milk. 

321  Lexington  Avenue. 


mm 


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rangement with  the  Librarian  in  charge. 

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'QP246 
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